1. Soltani gh. Associate Prof. of Anesthesia & Intensive Care ‍

2. Overview

3. Stroke Incidence Frank Stroke 2-6% for closed chamber & 4-13% for open chamber surgery 50% present in first 24hr post surgery Early Stroke tends to be more severe & with a higher permanent deficit & impact on mortality

4. Cognitive dysfunction 83% of all CABG pts (on pump) demonstrate a degree C. dysfunction 38% intellectual Impairment & 10% overtly disable At 5yr follow-up > 35% of CABG pts exhibit some degree of neuropsychologic dysfunction

5. Risk factors for neurologic complications in cardiac surgery

6. Etiology of CNS damage A. Embolization B. Hypoperfusion

7. Common Locations of Infarction

8. Embolic Sources A. Patient- related 1. Aortic atheroma 2. Intraventricular thrombi 3. Valvular calcifications B. Procedure - related 1.Open VS closed chamber 2.Aortic cannulation and clamping 3.Duration of CBP C. Equipment -related 1.Filters 2.Membrane VS bubbles oxygenators 3.Use of N2o

9. Hypoperfusion 1.Watershed area 2.Cerebral perfusion pressure 3.Circulatory arrest 4.Intra and Extracerebral atheromatosis

10. Perioperative strategies minimize CNS injury brain

11. Pharmacologic Cerebral Protection A. Metabolic Suppression 1. Thiopental 2. Propofol 3. Isoflurane B. Calcium- channel blockers C. Glutamate antagonists D. Serine Proteases E. Lidocaine F. Future avenues